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Position Summary

Position Summary:

Medicare and US Family Health Plan (USFHP) Appeal Specialists are responsible for processing of all member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals. The Specialists collaborates with Care Managers, Medical Directors and Compliance partners, as well as other internal and external partners to ensure a comprehensive appeals management process.

Job Description

Key Outcomes:

• For Medicare Focused Specialist:

• Researches, processes and resolves Part C reconsiderations with 100% compliance

• Prepares for, and participates in CMS, NCQA, and Health Plan audits

• Serves as the subject matter expert for Part C appeals Medicare Managed Care Manuals

• For USFHP Focused Specialist:

• Researches, processes and resolves all appeals in accordance with Tricare and NCQA guidelines.

• Serves as the subject matter expert for TRICARE and US Family Health Plan manuals and benefits pertaining to Member Appeals

• Prepares appeals documentation within contractual and regulatory requirements

• Independently manages multiple work queues, streams of correspondence from providers and members

• Determines the nature of appeals and correspondences and ensures adherence to Standard Operating Procedures (SOP) to determine next steps

• Evaluates medical claims and coverage policy documentation to determine validity of the appeal

• Data entry of appeals to track case details, correspondences, and monitor timeliness of resolution

• Maintains case files in organized and secure manner, both electronically and written

• Conducts telephone work with members, providers and third-party administrators

• Prepares case files on clinical member and provider appeals for review by clinical team members

• Prepares and sends appeal case files for all appeal levels in accordance with regulatory requirements

• Responsible for ensuring and monitoring effectuation of all decisions as a result of the appeal process

• Works with leadership to develop appropriate policies and procedures

• Brings trends and training opportunities to supervisors and management as appropriate

• Works collaboratively and effectively with all other departments and functions to maximize operational efficiency and service and ensure consistency in addressing appeals issues

• Maintains confidentiality while providing quality customer service to internal and external customers

• Cross-trains to perform either Medicare or USFHP Appeals Specialist functions as needed

Education/Experience:

• Bachelor’s Degree or equivalent experience and education

• 3+ years experience in managed care plan required; knowledge of Medicare Advantage (for Medicare Specialist) or TRICARE (for USFHP Specialist) appeals processes and regulations strongly preferred

Skills/Knowledge/Competencies (Behaviors):

• Demonstrates an understanding of and alignment with Martin’s Point Values.

• Excellent written and verbal communication skills

• Effective time management skills and organization skills

• Must have a track record of producing high-quality work: highly accurate, demonstrates attention to detail, and reflects well on the organization

• Strong interpersonal skills and the ability to collaborate with internal and external clients

• Excellent customer services skills

• Strong analytical, problem-solving and mathematical skills

• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint)

• Strong organizational skills and able to meet deadlines (ability to prioritize and multi-task while maintaining focus on objectives).

• Self-driven and self-motivated: ability to function independently with sound decision making

• Take appropriate initiative while soliciting input/advice appropriately

• Ability to handle confidential and sensitive information in a discreet and professional manner.

• Ability to handle high volume of work while maintaining accuracy and timeliness requirements

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org